Provider Demographics
NPI:1609532571
Name:DICKSON, SHANEYLIN (SLPA)
Entity Type:Individual
Prefix:
First Name:SHANEYLIN
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6745 E SUPERSTITION SPRINGS BLVD APT 1046
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4314
Mailing Address - Country:US
Mailing Address - Phone:425-373-6972
Mailing Address - Fax:
Practice Address - Street 1:2830 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5430
Practice Address - Country:US
Practice Address - Phone:425-373-6972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA134872355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty